Entrevista a Leslie Greenberg (2010)

David: You're the developer of an approach known as emotion-focused therapy. How long ago did you develop this approach?

Leslie Greenberg: Well, it's been in the making for many years. It didn't start off as an approach to therapy. It really started off as trying to study how people change. So, really, the first relevant publication was probably in about 1979, and then slowly over time it developed, and in around 1993 we wrote a book called Facilitating Emotional Change in individual therapy and in 1988 a book on Emotionally Focused Couples Therapy. So that was when it could be assumed to start.

David: And somewhere I read that you've been working on it for about 30 years in all.

Leslie Greenberg: Right.

David: Yes, now there are already a ton of therapies out there, so why did you think we needed a new one?

Leslie Greenberg: Well, I didn't. In fact, I was quite opposed to it. But the political and zeitgeist of the field, unfortunately, is that if the therapy doesn't have a name, then what you're really saying doesn't get heard.

David: Yes, I'm aware of that.

Leslie Greenberg: Right, so I was quite reluctant even to call it couples therapy, emotionally focused couples therapy, but it was sort of the pressure of the field and even the demands of the publishers and so on for naming books. And then with the advent of evidence-based treatment, it became essential to have an entity and a name. I still think it would be better not to have one.

David: Okay. Well, given that it does have a name and the demands of evidence-based therapy, tell us what emotion-focused therapy is.

Leslie Greenberg: Well, essentially it's a therapy that really focuses on working with lived emotion in the session. So whereas both psychodynamic and cognitive therapies tend to work more with conscious cognition, the emphasis in EFT is really on how to work with people's actual feelings in the session and then how to work with changing emotions in the session, so that the real emphasis is on trying to understand emotional processes and how emotions change.

David: So it's a very integrative approach as I understand it, combining client-centered, gestalt, and cognitive principles. And then it combines humanistic insights with an empirical approach.

Leslie Greenberg: Correct.

David: So can you tell us more about that?

Leslie Greenberg: Right, and it also includes interactional systemic perspectives when we're looking at the couples approach. I mean, the best way is tracing my own development: that I first trained as a client-centered therapist. I then trained as a gestalt therapist. I was very interested in research and studied Piagetian cognitive development, and I was really interested in studying the process of change, so I started off as a process researcher. So it was pulling all these influences together. And I used to be an engineer. I have a master's degree in engineering before I came into psychology, and so I was very interested in model building and studied Piaget's approaches to studying people - children - solving problems, and then tried to apply that to the affective domain of how do people solve problems actually in psychotherapy.
And so then I was putting all that together, and slowly it synthesized into an approach. Now, I viewed the relationship, the psychotherapeutic relationship, as also central and based that on a person-centered or client-centered approach and then was looking at change processes that were focused on emotion. And, having been an engineer, I had come to psychology with the idea that we know more than we can say, and that became known eventually in psychology as implicit knowledge or procedural knowledge. And I think I came as an engineer thinking that rationality was not the solution to human problems and that emotion was very important. So I was putting all those influences together.

David: Well, you might expect the reverse from an engineer: that you would have been more oriented towards the rational and a kind of mechanistic approach to things, but it sounds like that wasn't the case for you.

Leslie Greenberg: Right, because I had the sort of seminal experience of solving a math problem and having no idea how I went about solving that problem; that somehow something implicit was guiding that process. So that influenced me a lot to think that we know more than we can say, and that it's not a rational process, but that there's some knowing that is greater than what rationality can articulate. And I guess I'd always seen that people were not best described by a view that they were rational; that there were other forces motivating people.

David: Yes. That's a fascinating story about that solution to the math problem. Now, you call your approach emotion-focused. There's been so much emphasis on cognition, as in cognitive-behavioral therapy. Why emotion-focused?

Leslie Greenberg: Well essentially, I think it's because the zeitgeist became so dominated by cognitive-behavioral, and then there were interactional and systemic therapies, so it's like what's missing? What's missing is a focus on emotion, and I also studied systemic interactional therapy at MRI in Palo Alto, and each time I was bumping up against the dominant paradigms, it was clear to me that they were missing what I saw as the crucial element, which was emotion. So it became sensible both to call it emotion-focused therapy and also to essentially contrast this with the cognitive therapy.

David: Yes, I'm thinking maybe that your experience with gestalt therapy might have had some impact there, too. It seemed to me that a lot of… back in gestalt therapy's heyday - and I don't think we're in that heyday now - but that there was a lot of emphasis on emotional expression, emotional abreaction, if you will.

Leslie Greenberg: Yes, absolutely. All the humanistic therapies worked a lot with emotion, so client-centered therapy was working with experiencing, which was a combination of feeling and meaning. And then, yes, gestalt therapy had a strong emphasis on emotional experience and expression, and so I did grow up, so to speak, in the early '70s within the humanistic movement. And I mean there were things like primal scream and bioenergetics and gestalt, and they were all promoting different variations of emotional expression, but nobody had a clear theory or understanding or set of principles to guide what do you really do when you work with emotion.

David: Interesting. I came up through that same tradition, so I'm quite familiar with everything that you're referring to. Go ahead. I think you hadn't finished your thought.

Leslie Greenberg: Right, so you mentioned abreaction and catharsis, so somehow that didn't seem to me to capture what was really going on. And sometimes I saw very good change processes occurring when people expressed emotion, but clearly sometimes emotions were disruptive and were not helpful. So I began to try to look at what… to have a more differentiated view of how emotion works. But clearly this did come from my gestalt therapy and also my client-centered therapy and work, right.

David: One of the things that I observed from that period was it seemed that there was a possible pitfall of people getting hooked on or addicted to acting out emotionally.

Leslie Greenberg: Right, so just emotional expression for expression's sake became seen as a seen as a good thing by some people. Because actually the theory of gestalt therapy was not that; it was that awareness was what was the key. But there was a lot of yelling and screaming and crying, and full of sound and fury signifying nothing type of thing.

David: Yes, and so you say that you wanted to develop a more differentiated approach. So say something about that differentiation?

Leslie Greenberg: Well, so we started with… I was really interested - and this did come from my experience in gestalt - that somehow my trainers used to be able to discriminate between some emotions as authentic - some emotional expressions as authentic - and some as not authentic, essentially. So then I started to try to understand this in as broad a sense as possible. So I came to define at a clinical level, also informed by my understanding of the theories of emotion, that there are primary emotions, which are the very first emotions you feel, and then there are secondary emotions which are somehow emotions that are reactive to the primary emotions or that are emotions about the primary emotions. The things like you express anger when really you primarily feel hurt.
And then it was important to make a distinction that some emotions are being used for effect. They're instrumental; they're in order to achieve an aim; or they could be manipulative. But somehow they're being expressed for the impact on the other, like crying crocodile tears. So it became important to distinguish is this a primary, a secondary or an instrumental emotion? And then when you get to primary emotions, essentially is it an adaptive emotion that gives you good information that you can trust and rely on to guide you? Or is it a maladaptive emotion which, because of traumatic learning or some sort of past history, it's become maladaptive and you no longer can trust and rely on that.
And that's what the humanistic movement didn't have, is this kind of discrimination of different kinds of emotions.

David: That's a very helpful answer. It really makes clear what you're talking about when you talk about differentiating, having a more differentiated model. I was on your website and was interested in the list of things that emotion-focused therapy seems to be good for. Maybe we could step through some of those bullet points that I saw on your site; for example, those who obsessively over-control their emotions.

Leslie Greenberg: Yes, in a way that's who it's most directly… almost easily able to understand how it's helpful for those people. So people who over control and/or who intellectualize can't use their emotions as a guide. So I think maybe the important thing is to step back another step and just to say that the revolution in the understanding of emotion is that basically emotion is now understood to be fundamentally adaptive; so it's aided our survival; it's helped us both interpersonally and intrapersonally. So emotions really are basically adaptive.
So if you don't have access to your emotions, you're missing a very intelligent source of information that generally guides adaptive behavior. So if you over control your emotions, if you over intellectualize, you just don't have access to how you're actually reacting to situations, so you are not oriented well in the world. I mean, if you feel angry at somebody or something, but you don't know that you're angry, you're going to be disoriented in the world.

David: Is that more of an issue for upper middle class and upper class Anglo-Saxon people, Caucasian people, than for maybe other populations?

Leslie Greenberg: No, I think it's more complicated than that. Clearly that kind of population is more restricted in its emotional expression but not necessarily in emotional awareness. That can run across the spectrum, so that very less psychologically sophisticated or intellectually developed people, especially men, have very little access to their emotions, regardless of what socioeconomic class they are. So I mean lower socioeconomic class may have less awareness of their emotions.

David: So you may act out your emotions, you may be a very emotional person, but not have that awareness?

Leslie Greenberg: Right. That's a good point. Another problem with non-awareness of your emotion is you might actually act it out, so you might be violent; you might do impulsive things. And that's really because you have no awareness of your emotions and no ability to symbolize them and reflect on them. You just act them out.

David: Okay. Another point on your website was that emotional-focused therapy is good for differentiating between unconstructive and constructive unpleasant emotions. So are you saying that unpleasant emotions can be both unconstructive but also constructive? Tell us about that.

Leslie Greenberg: Yes, so that's really the distinction between adaptive and maladaptive emotions. So anger can be empowering anger, which is constructive and healthy, or anger can be maladaptive and destructive. So it's almost like anger stated in the I language, like "I am angry at you," is very different to anger stated in the you language, which is "you are a… xyz," right? You can insult or denigrate the other. So there's empowering anger and there's destructive anger.
We talk about weeping type 1 and weeping type 2. There's weeping which is a sign of working through of distress, and then there's weeping which is a sign of distress, so that it's distress about distress. So there can be healthy weeping and grieving and unhealthy weeping and hopeless, helpless weeping. So in all cases there can be both adaptive and maladaptive or constructive and unconstructive emotion.

David: Okay, that's clear. Now, you also talk about tapping the directional wisdom of emotions. What do mean by that - the directional wisdom?

Leslie Greenberg: Well, emotions are most characterized in their early form as having action tendencies. So when I first came as an engineer into psychology, I remember that I thought of emotion as something inside of myself. But as I started to study and understand, I realized that emotion is most fundamentally an action tendency - a tendency to act. So in fear we're organized to flee; in sadness we're organized to cry out for the lost object; in anger we're puff up and thrust forward to protect our boundaries. So actually is giving us a sense of direction. So that's a part of the way emotion moves us and emotion informs us. So it organizes me to act in a certain way, and it tells me how I'm reacting to situations, because the thing I haven't said is, not only is emotion adaptive, emotion is a rapid-action adaptive system, and it's automatic. So we just react very rapidly emotionally, and that's how it gives us a sense of direction.

David: And yet that word "wisdom" is in there. I'm interested in that; you talk about the directional wisdom. Where's the wisdom? In what way does it let us tap into wisdom?

Leslie Greenberg: Because actually emotion is our most fundamental way of processing, and we do it… Emotion ultimately is a very high level synthesis of everything we know going on automatically. We know far more than we can say, and so emotion is like a… there used to be a term in psychology, people used to study "apprehending." It's like a global apprehension; it reads patterns outside of our awareness.

David: Yes, this reminds of Malcolm Gladwell's book Blink, which in part draws upon research to establish something very similar to that idea.

Leslie Greenberg: Exactly, exactly. Yes. That is very much the same concept.

David: Okay, now you also talk about harnessing the power of emotions for positive change. Tell us something about that.

Leslie Greenberg: Well, the issue is if we can get access to our adaptive emotions, it helps move us and inform us in good directions, so that this is allied to probably the most fundamental principle of emotion-focused therapy, which is that the best way to change emotion is with another emotion, possibly a stronger and opposing emotion. So in simple terms, anger can change fear because in fear we're organized to step backwards or we're organized to run away. In anger we're organized to puff up and thrust forward. So if when you're afraid you can access empowering anger, anger will change fear. So there, by that process, we mobilize the healthy emotions to help transform the unhealthy emotional responses.

David: Something you said earlier made me think that I should ask you what your theory of change is, and I think you've just been speaking to that, but if I were to ask you that question - what's your theory of change - is there anything that you would say beyond what you just said about replacing one emotion with another?

Leslie Greenberg: Yes, because this is what EFT, emotional-focused therapy, is really based on, that we study change. So we have lots to say about change. In fact, it's the most researched therapy on how change actually takes place. So, at the most global level, our hypothesis, which we've tested and provided evidence for, is that reflection on aroused feeling is the main change process. So the goal is to arouse people's feelings and then to get them to symbolize these, reflect on them, and ultimately change narratives. So we've got a combination of emotional arousal and then cognitive reflection on the aroused emotion.

David: And then changing the narrative. I think that's an interesting third piece that you put in.

Leslie Greenberg: Right, right. So life is a process of making sense of our feelings, and so we are helping people in therapy make sense of their feelings. That's the most global principle. Then I've stated six fundamental principles, and these are all change processes, and that is awareness of emotion, expression of emotion, regulation of emotion, reflection on emotion, transformation of emotion by other emotions, and having corrective emotional experiences with other people. So those are six basic change principles.
And then, not to overwhelm too much, but then we study specific change processes, so the whole therapy is based on that people have different emotional types of problems and that each problem is solved by a very specific process. It's like self-criticism is one problem, and that's different from problematic reactions. Problematic reactions are those situations in which people puzzle about why they reacted in a certain way, whereas self-criticism is where they negatively judge or evaluate themselves. So those are two different states of mind, and then we've studied how do people change in each of those contexts. So we have very specific change processes.
So one of the problems with the different therapies has been - and the therapy wars - is that they somehow pivot on a single change process, and everything becomes is it making the unconscious conscious? Is it changing cognition? Those are far too global and simple. Therapy's a much more complex process and they're all right and they're all right only in some specific situations.

David: Yes, and so one of the things I'm hearing in what you're saying is it almost sounds like there's a diagnostic process at the beginning, where you have to figure out what is the emotional difficulty here specifically, and it sounds like that doesn't necessarily articulate with the DSM.

Leslie Greenberg: Absolutely. So we have proposed what we call process diagnosis as opposed to person diagnosis, and this is even more refined than case formulation. So, yes, the DSM is minimally helpful for how do you treat people. It's not a functional diagnostic system. Once you know somebody's depressed, it doesn't tell you how to treat them. People will be depressed for many different reasons, and then, in addition, they will manifest or they will organize differently when they're in psychotherapy sessions. And what we do is work with how you're organized in the therapy session. What's the best way to work with you when you are self-critical in the therapy sessions?

David: That's fascinating, and it certainly makes a lot of sense to me. Now earlier, you alluded to having written a book on couples work.

Leslie Greenberg: Right.

David: How do you work with couples?

Leslie Greenberg: Well, the essence of our couples therapy approach is that couples get into negative interactional cycles like blame-attack-defend or dominate-submit, and that this is driven by the inability to reveal underlying vulnerable emotions related to attachment and identity, so that if I'm feeling sad and lonely about you being distant, my partner being distant, I end up often blaming you. And what I'm not doing is telling you that I'm sad and lonely. So we have great difficulty revealing our underlying vulnerable feelings, and we end up attacking each other.
And so the basic change process is helping people to reveal their underlying attachment oriented feelings - that's about closeness and distance - and their underlying identity related feelings, which is often about validation and invalidation; so that when I feel invalidated by you, I feel shame, but I end up either withdrawing or attacking. But we're unable to deal with really revealing our core selves to each other, and when we do reveal ourselves to each other in non-demanding and non-attacking ways, usually from loving partners it evokes compassion rather than defense or counterattack.

David: Fascinating. As somebody who's been married for a long time, I recognize everything you're talking about.

Leslie Greenberg: Right. You know, one of the things about our approach is, in many ways, we've tried to articulate more explicitly what many people recognize as what they fundamentally learned as therapists, but it's never been organized in such a specific and explicit manner. So in some way it's been trying to make the implicit therapeutic knowledge much more explicit.

David: Yes, and in fact your website also lists research being… let me start that again. You've actually done research on the efficacy of emotion-focused therapy at York University in the process of making all of this information more explicit. What have your findings been?

Leslie Greenberg: Well, basically we've shown that emotion-focused therapy is effective for depression; that it's more effective than the empathic therapeutic relationship alone. It's more effective in changing interpersonal problems than is cognitive therapy; so there was a trial comparing emotion-focused therapy to cognitive therapy by Jean Watson, a colleague and ex-student of mine. We've also shown that it's effective for resolving unfinished business or what we are calling emotional injuries; that it promotes forgiveness. So these are the sort of basic outcome results.
Now there's recent research showing its effectiveness in eating disorders, with bulimia. There's current work going on about treatment of anxiety disorders, and then another one my ex-students, Sandra Paivio, has shown its effectiveness for complex trauma, and specifically has studied women who've been sexually abused or raped, and it's been shown to be effective. So there are a variety and growing number of effectiveness studies, and the couples therapy has been shown to be effective for marital distress as the main item, but for depression, for issues of infidelity and emotional injuries. So there's a whole set of outcome studies.
But more importantly, we've tried to study what are the change processes, so in general, it's not just does a therapy work. In my view, most therapies work. There's the common factors which account for a large percent of the variance, so the real issue is what is the change process in this therapy and is it that that is producing change? So we have attempted to study the specific change processes, and I've mentioned some of those already.

David: Well, this sounds like a wonderful research process that you have going on here and with some pretty amazing sounding results. What sort of success are you finding - or resistance - in the field? I think it's hard to get these ideas out there is my guess.

Leslie Greenberg: Absolutely. The field is politically and power based. Certain people control journals, research grants, and ultimately it comes down to practice and training. So, unfortunately, cognitive-behavioral therapy has become the new psychoanalysis. Whereas psychoanalysis used to control the field, now cognitive-behavioral therapy controls the field. And the whole evidence-based movement in some ways, although it maybe started off with a benign intention or motivation to demonstrate the effectiveness of psychotherapy vis a vis the medical treatments, essentially, in my view, it's become a power play in the field, and it's very unfortunate.
So psychotherapy is a very complex area. People's identities are so involved in the therapies, and essentially people are protecting territory and identities, and they propose it as knowledge based, but it isn't, in my view, so that it's very difficult to have a voice against the dominant paradigm.

David: Yes, and I've heard this from some of my other interviewees as well, so I really do see that that is a major issue out there. Now, we have two sorts of listeners to this series: therapists and also people who are potentially clients, people who are interested in psychotherapy, perhaps people who are seeking psychotherapy for themselves or for people in their families or friends. And so let me ask you, for the first group, for therapists, if they were interested in finding out more about this approach or getting training, how would they go about that?

Leslie Greenberg: Well, I have a new website, actually, which is www.emotionfocusedclinic.org. That's the best way to access training. I do intensive weeks here in Toronto of training, and I also do different kinds of training workshops. So it really is important to get an actual training. There are books and there are videotapes. The majority of books and the videotapes are available through APA, American Psychological Association. So those are good training resources, but otherwise I think a real training… And the trainings also are experiential, so that people actually come and learn the skills by working with their peers. So they're actually doing skill training; it's not just conceptual book learning.

David: Yes, that's so important. And how would a listener find a practitioner in their area?

Leslie Greenberg: Similarly, on this website, www.emotionfocusedclinic.org, there is a list of all people who've taken the training and at what level they're trained at. So that would be… and the area in which they are. So that is being built up as a source.

David: Excellent. Well, as we wind down here, is there anything else you'd like to say?

Leslie Greenberg: I do think that everybody has an intuitive understanding that emotion somehow is very important in human life. And yet, one of the things as I've traveled around the world, taught in many places, one of the real human phenomena is that people also are afraid of emotion because emotion can be very painful. And so one of my doctoral students had a title on his doctoral dissertation of "How Can Feeling Bad Lead to Feeling Good?" So most people avoid negative emotions, and yet what emotion-focused therapy is saying we have to overcome this avoidance, and we do have to face our painful feelings, but that that is a path to change. And so I think we both have emotions; we're wired to have emotions; we're also wired to be afraid of emotions. Emotion avoidance is a significant problem. Needing a safe relationship - people need a safe relationship and then they need to be able to face painful emotions. And that's a very important human process.

David: Well, that's a great wrap-up. Dr. Leslie Greenberg, thanks so much for being my guest on Wise Counsel.

Leslie Greenberg: Thank you.

Les Greenberg

Emotion Focused Therapy

Terapia focalizada de las emociones (PDF)

Entrevista sobre integración en psicoterapia y gestalt

dc